To identify perceived barriers and strategies related to gender-inclusive medical leadership and to determine whether there are gender differences in these perceptions, we sent a 21-item, web-based survey to all active faculty members and trainees (residents and fellows) in a large academic pediatrics department. The overall response rate was 56.9% (156/274) with a 64.5% response rate for faculty (131/203). Respondents highlighted multiple barriers to women in leadership (family responsibilities, lack of guidance, implicit biases), as well as multiple strategies to address gender disparity (organizational changes, increased guidance, support for family responsibilities). We found significant gender-based differences: 61.7% of men reported that leadership opportunities for women and men were the same, whereas 62.6% of women reported women’s opportunities were inferior; in terms of networking opportunities, 66% of men reported they were the same, whereas 65.9% of women reported they were inferior for women. More women than men cited organization-related challenges and strategies related to women in leadership; men selected more individual-related challenges and strategies. Men and women differ in their perception of the existence and causes of gender-related issues in high-level leadership and of the best approaches to improve gender diversity in leadership. These results may explain why gender disparity is ongoing, even in a pediatrics department where the majority of faculty are women.

Gender diversity in leadership increases productivity and innovation,1-4 improves decision-making,2,5 and increases engagement of team and organizational members,3,6 all of which contribute to improved patient care and outcomes.1,7 Despite these known benefits, disproportionately fewer women are promoted to full professor8-14 in research tenure tracks12 and in high-level medical leadership roles (e.g., department chair, division director) in most academic medical institutions in North America.8,10,12,15-18 It is frequently argued that the gender gap will close “naturally” over time because of the increasing numbers of women in medicine. However, even in pediatrics, where women have represented close to 50% or more of the faculty for the last 15 years,19-21 women continue to hold significantly fewer leadership roles than men.22,23

In our Department of Pediatrics at McGill University, one of the largest in Canada, women represent 60% of the faculty, yet remain underrepresented in high-level roles. At the time of our study, only 26% of full professors, 33% of division directors, and 14% of associate chairs were women, and neither the vice-chair nor chair were women. Even 20 years ago, when potential leaders were starting their careers, pediatrics included about 40% women21; thus, these statistics still show a disproportionately low number of women.

Although studies describe gender differences in perception of personal barriers to leadership,12,16,24,25 there is a paucity of literature examining gender-based perceptions of barriers and solutions regarding women in leadership. Therefore, the aim of this study was to identify such barriers and strategies and to determine whether men and women have different perceptions.

Methods

Study sample

Our study consisted of a department-wide survey in the Department of Pediatrics at McGill University. Survey invitees included 71 trainees (residents and fellows) of whom 73% were women and 203 clinical and PhD research faculty, i.e., assistant, associate, and full professors (60% women), who would be eligible for leadership positions in our department currently or in the future. In our department, trainees at all levels have leadership opportunities and were included to ensure generalizability of our results.

Survey

In line with our goal to study gender-based perceptions, we chose a survey design that allowed self-reported, anonymous responses. A 21-item structured survey was developed by the research team and included questions that were based on previous work,5,24,26-29 but modified for our local context (see appendix). Face validity was established with a broad spectrum of male and female department members at various leadership levels and academic ranks (including the trainee level).

The questions fell into three main domains: (1) demographics e.g., gender, number of years since primary degree of appointment i.e., years since obtaining the degree for which the respondent was appointed in the department), current academic rank, (2) personal leadership experience e.g., personal importance of leadership, personally experienced barriers to leadership), and (3) general views on leadership e.g., perceived challenges to women seeking leadership, perceived leadership and networking opportunities for women compared with men, perceived strategies to enable women to take on leadership positions). To maintain anonymity, leaders were defined as respondents who self-reported currently holding or having held a leadership position within the department, university, and/or nationally/internationally.

The web-based survey was sent to eligible departmental trainees and active faculty members using Lime Survey, an open-source tool. Email reminders were sent to invitees twice a week until there were no new responses for three consecutive days following a reminder. Digital data were stored in secure computer files. Data for cells smaller than three individuals were not reported to prevent identification of respondents. To encourage participation, respondents were eligible for a draw of two $25 gift certificates if they provided their contact information. Respondents’ contact information was not stored with survey responses.

SPSS software was used to analyze the survey data, using independent t tests and χ2 analyses as appropriate. A p value of 0.05 was taken as significant. In addition, we explored associations between key outcomes and relevant covariates using appropriate methods of logistic regression using Stata v. 12 (StataCorp, College Station, Texas). The key outcomes were: perception of leadership opportunities for women, importance of leadership roles, and perception of opportunities for informal networking. Multinomial, ordered, and logistic regression were used to estimate odds ratios (OR), adjusted odds ratios (aOR) and their 95% confidence intervals (CI). Models were adjusted for respondent gender, number of years since primary degree of appointment (e.g., MD or PhD), current academic rank, and self-report of having held a leadership position.

challenges to women seeking leadership, and perceived top three strategies to enable women to take on leadership positions, were also collected.

Ethics

Our University Health Centre Research Ethics Board reviewed the study and waived the need for Institutional Review Board approval. Informed consent was obtained from survey respondents to publish the study information. Top

Results

The survey remained open for 23 days. The overall response rate was 56.9% (156/274), representing a 64.5% response rate for faculty (131/203) and a 35.2% response rate for residents and fellows (25/71). Of the 156 respondents, 66% identified as female (n = 103) and 32% as male (n = 50), which paralleled the gender distribution of those invited to participate in the survey, i.e., 63.5% women and 36.5% men. The three remaining respondents were excluded from the results because their answers to the gender identity question created cells smaller than three. All except one of the 15 divisions in the department had both female and male faculty representation (one division’s faculty are all female).

The median number of years since primary degree of appointment was similar for women (18 years, interquartile range [IQR] 8–26.5) and men (20 years, IQR 9–31, p = 0.21; Table 1). However, there was a significant difference between women and men in the median number of years since appointment in the Department of Pediatrics: women 10 years, IQR 3–19; men 18 years, IQR 6–25, p = 0.022; Table 1).

There was no gender difference in the perceived importance of achieving a leadership position (median 4 on a scale of increasing importance, 1 to 5; p = 0.34, aOR 0.69, 95% CI 0.34–1.38; Table 2). However, there were significant gender differences in perceptions of the existence and causes of gender disparity in leadership. Significantly more women than men perceived leadership opportunities as inferior for women (62.6%, n = 57) whereas most men (61.7%, n = 29) perceived the opportunities as the same (χ2 = 12.46, p = 0.01, aOR 4.44, 95% CI 1.85–10.69; Table 2). Multivariate logistic regression did not reveal significant differences in the perception of leadership opportunities for the other variables tested, i.e., number of years since primary degree of appointment, current academic rank, and leadership role.

In addition, significantly more women than men (65.9%, n = 60 vs 34.0%, n = 16) perceived women’s networking opportunities as different from those for men (χ2 = 12.78, p = 0.002, aOR 5.94, 95% CI 2.43–14.51; Table 2). Multivariate analyses revealed that respondents (women and men) who were leaders, as well as those who were trainees were more likely to perceive women’s networking opportunities as different from those of men (aOR 3.74, 95% CI 1.52–9.20, OR 5.26, 95% CI 1.36–20.26, respectively; Table 2).

When asked about personally experienced barriers to attaining leadership, 41.2% of women

(n = 40) and 22.4% of men (n = 11) affirmed such experience. There were no significant demographic differences between the men who reported barriers and those who did not. However, women who identified as leaders were more likely than non-leaders to report experiencing barriers (OR 5.09, 95% CI 2.04–12.7). When asked to choose from a list of barriers, these 11 men and 40 women reported experiencing the same top three: “not being identified and guided for leadership positions,” “lack of mentors,” and “family responsibilities” (Figure 1).

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In contrast, there was gender disagreement related to perceived challenges for women in general and strategies for gender-inclusive leadership. When asked to select, from an itemized list, the top three challenges that women face when seeking leadership, more women than men chose organization-related issues, i.e., “not being identified or guided for leadership positions” (30.1% of women vs 16% of men), “non-shared leadership positions” (11.6% vs 2%), and “lack of leadership education and knowledge” (10.4% vs 2%) (Figure 2). In comparison, more men than women thought that women face individual-related challenges, such as “family responsibilities” (70.0% of men vs 55.3% of women), “concern over the position getting in the way of personal life” (32% vs 23.3%), and “difficulty getting on leadership track following parental/medical/personal leaves” (30% vs 7.8%).

Similar gender discrepancies were observed when participants were asked to choose the top three strategies that would enable women to seek leadership positions (Figure 3). Although over 30% of both women and men selected “mentorship,” women chose additional organization-related strategies more than men: “better/more administrative support” (44.7% of women vs 30.0% of men), “support network” (28.2% vs 20.0%), and “flexible hours” (25.0% vs 14%). In contrast, more men than women chose strategies related to the individual, such as “developing personal effectiveness” (36% of men vs 19.4% of women) and “daycare on-site” (28.0% vs 12.6%). Top

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Discussion

Through this department-wide survey, we found important differences between men’s and women’s perceptions of the existence and causes of gender-related issues in medical leadership and best approaches to improve gender diversity in medical leadership. These findings are novel and will contribute to innovative approaches to achieving gender-inclusive leadership.

As expected, significantly more men were full professors and leaders; however, this gender discrepancy was not a result of motivation, as there was no difference between men and women in terms of the personal importance of achieving a leadership position. Most of the men in our study perceived that leadership and networking opportunities (important for career advancement) are the same for men and women, which highlights a disconnect from most of the women who perceived inferior leadership opportunities and different networking opportunities, as also noted in the literature.5,10,11,30,31 These gender-discrepant perceptions represent major barriers in and of themselves, given that most of those currently holding leadership positions and, thus, responsible for departmental changes and advocacy are men, who may be unaware of the obstacles women experience.

Our results also demonstrate gender disagreement related to perceived challenges and strategies to enable women to attain leadership positions within our department. The leadership barriers most frequently selected by men and women (Figure 2) are consistent with those emphasized in the literature including: lack of guidance through mentorship and networking,11,29,30 disproportionate caregiving responsibilities for women,11,13,31-33 lack of a family-friendly work environment,5,25,31 and gender-biased selection of leaders.5,34

Although men viewed women’s main challenges as individual-related, most of the 11 men who personally experienced barriers to leadership, reported organization-based barriers, as did the 40 women who experienced barriers

(Figure 1). Likewise, in terms of strategies to enable women to attain leadership, women emphasized improvements in the organization, whereas men chose strategies related to improvement of women’s personal effectiveness (Figure 3). Top

We did not validate the truth of these perceptions, but focused on the perceptions themselves, knowing that they may drive actions and decisions and, thus, affect the problem of gender bias. These findings highlight the need to sensitize our current leaders (who are mostly men) about the existence of gender-discrepant perceptions of causes of and solutions to the gender gap in leadership. The results also

underscore the need to shift the focus to organization-related changes to enable women, as well as some men who may also not be included in the current pool of leadership candidates, to apply for and assume leadership positions. This is aligned with findings by Carr et al.30 that demonstrate that most institutions using strategies to support gender equity are focused on individual and interpersonal strategies, rather than organizational-level initiatives

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These results fit with research that examines gender inequality in terms of supply and demand.35 The supply side of increasing the number of women in senior leadership roles focuses on how to change the women in the labour force (e.g., personal development). In contrast, the demand side focuses on structural accountability, such as changes to the jobs being offered and the processes through which leaders are selected. The supply side, emphasized by the men in our sample, has been more prominent in the past, but this approach has achieved limited results. The demand side, which the women in our sample favoured, is less common, but research suggests that this approach is more effective for increasing female representation in leadership today.36

Our study has some limitations. First, although our faculty response rate of 64.5% was in keeping with other published studies of similar scope,12,37,38 we had a poor trainee response rate. This may be because the survey’s focus was on faculty leadership as opposed to resident and fellow issues. Therefore, important insights related to barriers and strategies experienced before beginning as a faculty member may have been missed. Second, a survey-type study cannot tease out the nuances about why specific types of barriers and strategies were selected. Future research using semi-structured interviews could answer such questions. Third, our results are based on a relatively small sample (which limited some subanalyses) in a specific hospital and university context and, therefore, may not be generalizable. Although our data regarding the existence and causes of gender disparity are consistent with the literature, future research should validate our findings related to gender-based perceptions in other hospital and university settings.

Finally, the emphasis of our survey was on clinical and educational leadership with fewer questions related to leadership in a research context. Future studies should aim to establish a definition of research leadership, which is not well delineated in the literature, and assess perceptions about challenges and strategies to women in research-related leadership.

In conclusion, we found that men and women differ in their perceptions of the existence and causes of gender-related issues in leadership and the best approaches to improve gender diversity in these positions. This may be an important contributor to the persistence of gender disparity in medical leadership even in pediatrics departments, where

most of the faculty are women. Future efforts to increase the number of women in medical leadership should include enlightening departmental members, especially leaders, about deeply embedded implicit biases and gender-discrepant perceptions. Top

The authors thank Michael Shevell, MDCM, Departments of Pediatrics and Neurology/Neurosurgery, McGill University and Montreal Children’s Hospital for prioritizing and supporting this project within the department; Jean-Pierre Farmer, MDCM, neurosurgery, pediatric surgery, oncology and surgery, McGill University and Montreal Children’s Hospital; Maria Psihogios, MD, PGY3, Department of Pediatrics, McGill University and Montreal Children’s Hospital, and Christine Sabapathy MD, MSc, Division of Hematology-Oncology, Department of Pediatrics, McGill University and Montreal Children’s Hospital for assistance with survey development; Jing Yang Xiao, Faculty of Medicine, McGill University, for survey data collection; Shauna O’Donnell, MSc, Research Institute, McGill University Health Centre (MUHC) and Nicholas Winters, MSc, Research Institute, MUHC for assistance with analyses. None of these people has any conflict of interest.

The Department of Pediatrics, McGill University funded the set-up, management, and data extraction for the online survey and data analysis and interpretation. The funding source was not involved in the study design; the collection, analysis, and interpretation of data; the writing of the report; or in the decision to submit the article for publication.

Author attestation

LHP conceptualized and designed the study, designed the data collection instrument design, coordinated and supervised data collection, acquired departmental funding, assisted with data analysis and interpretation, and drafted the initial and final manuscript; SZ conceptualized and designed the study, assisted with the creation of the data collection instrument and data interpretation, and reviewed and revised the manuscript; SL, JO, JP, AR assisted in the conceptualization and design of the study and creation of the data collection instrument and reviewed and revised the manuscript; IC carried out the initial and further analyses, assisted with data interpretation, and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Financial disclosure: The authors have no financial relationships relevant to this article to disclose.

Conflict of interest: The authors have no potential conflicts of interest to disclose. Top

Samara Zavalkoff, MDCM, FRCP, is an assistant professor in the Department of Pediatrics, McGill University, and program director, Division of Pediatric Critical Care, Montreal Children’s Hospital.

Stephen Liben, MD, FRCPC, is a professor in the Department of Pediatrics, McGill University, and director of the Pediatric Palliative Care Program, Montreal Children’s Hospital.

June Ortenberg, MD, FRCPC, is an assistant professor in the Department of Pediatrics, McGill University, and an attending physician in general pediatrics, Montreal Children’s Hospital.

Joyce Pickering, MD, MSc, FACP, FRCPC, is an associate professor in the Departments of Medicine and Epidemiology and Biostatistics, McGill University, and executive associate physician-in-chief of medicine, McGill University Health Centre.

Aimee Ryan, PhD, is the interim deputy executive director/deputy chief scientific officer of the Research Institute, McGill University Health Centre; the interim head of child health research, Montreal Children’s Hospital; and an associate professor in the Department of Pediatrics and Human Genetics, McGill University.

Ingrid Chadwick, PhD, is an associate professor of management at the John Molson School of Business, Concordia University.